Pain scale

Sparki77 · Jan 9, 2018

Based on the the numbers you've provided, I have given the pain medication. But there are a number of factors to consider: yes, every patient is different but also what is the med prescribed for? POD 2? Chronic pain? Are they opiate naive? Age? Last dose? Etc etc etc.

Ideally, pain should be kept under control as you don't want the patient to be chasing the numbers all night. I have found too often that nurses are hesitant to administer narcotic pain medications even if they fall within the parameters. I would also mention it to the prescriber when they round & pass it off during shift report. ( As a side note I wouldn't give it early without an order. )

xoemmylouox, ASN, RN · Jan 9, 2018

To be honest, it depends on the ordering MD. Some are VERY particular and will make your life living hell if you give narcotics outside of the parameters they set. Most of the time it is the ortho surgeons who feel the need to micro manage every aspect of their patient's post op care. Many are also trying to step away from narcotics all together. So for me it honestly depends.

JKL33 · Jan 9, 2018

So for example, say a patient can have Norco. The pain scale listed for it is say 5-7/10 Pain. If the patient states their pain is a 4, would you still give the Norco?

It depends on whether it is being used as a general guideline or if it's actually part of the order. If it's part of the order then I play by those rules - meaning I would offer whatever medication is able to be offered (according to orders) for a pain level of '4' and if that was felt to be inadequate I would call the provider.

I can see including these pain scale ranges as part of the order was reasonable but it boils down to more cook-bookery and more things for meddlers to nit-pick. Nurses will worry about giving norco to someone whose pain is "only" a '4' - even though for some patients a '4' might mean significantly distracting or bothersome pain. Meanwhile, the patients who want norco already figured out which pain scale numbers allow them to have norco.

Whatever. Yes, if I am boxed in by the way an order is written I will be calling someone.

PeakRN · Jan 9, 2018

If you are giving a medication outside of order parameters that is practicing medicine. You could call the ordering provider and clarify the order or to get an order for another medication (for example ultram, tylenol, motrin, et cetera). You could clarify the pain scale with the patient and see if they would still rate themselves at a 4 (I am not suggesting telling the patient that they only get X if they say their pain is a Y).

There are reasons that we do not want to treat mild pain with narcotics. I would suggest reading up on opioid induced hyperalgesia, we are not doing a favor to our patients by giving them more than they need, not to mention that we could be causing them to become addicted and have a whole different problem. Narcotics also have other side effects that harm patients, and we should not be giving them medications of any kind that they do not need. We don't (or I guess shouldn't) give antibiotics to someone with a cold so why would we give a narcotic to someone with mild pain?

MunoRN, RN · Jan 9, 2018

What differentiates "practicing medicine" and acting with the scope of an RN is whether or not you are acting within the mutually understood interpretation of the order between the ordering provider and the nurse. In my experience with the exception of possibly the initial dose(s), providers don't typically intend for this to be an ongoing replacement for critical thinking individualized to the patient.

There's also the issue of whether "dosing by the numbers" is appropriate based on practice guidelines. From a joint position paper by the ASPMN and the American Pain Society: "Prescribing a specific dose, based on a unimodal pain intensity rating, is not appropriate or safe". In my experience providers typically expect that the nurse will follow established practice guidelines, such as this from the ASPMN, when interpreting the order. So if that's the providers expectation of how the order will be interpreted, then you're not "practicing medicine".

So then how did dosing-by-the-numbers become commonly included in analgesia orders? The recommendation came from a faux practice guidance group called the American Pain Foundation, not to confused with the legitimate practice organization The American Pain Society. The American Pain Foundation was a group funded almost completely by opiate manufacturers, primarily Endo, the makers of Opana and Percocet. They eventually became defunct as a result of a Senate investigation, but not before successfully lobbying EMRs to template the dosing-by-the-numbers to all analgesia orders.

RNperdiem, RN · Jan 9, 2018

If that 4/10 pain is from a patient lying in bed, and I know the physical therapist is on the way, I would give the stronger medication.

A lot also depends on the department you work in.

I work in surgical ICU where the patients are monitored, the surgery is recent, and the pain can be intense.

JKL33 · Jan 9, 2018

They eventually became defunct as a result of a Senate investigation, but not before successfully lobbying EMRs to template the dosing-by-the-numbers to all analgesia orders.

Yes.

It doesn't even appear to be something any particular provider specifically preferred with any given order. It has just become part of the EMR templates.

Providers do believe that nurses will utilize established practice guidelines. Unfortunately neither the existence of those guidelines nor the provider's belief that nurses will utilize them in decision-making is any solid defense, practically-speaking, against the recent campaigns to reduce nurses' need to think critically. Nurses should understand how all of this is interpreted in their own facility and make decisions accordingly.

PeakRN · Jan 9, 2018

What differentiates "practicing medicine" and acting with the scope of an RN is whether or not you are acting within the mutually understood interpretation of the order between the ordering provider and the nurse.

I assume (yes I know) that if nurseequestrian is asking about how nurses handle orders in an EMR that she does not have an understanding with a physician. Even if the Doc is okay with you giving meds outside of their orders if you are documenting pain as a 4 and giving a med ordered for pain 5-7/10 they should still be changing their orders. If something goes wrong or a patient complains its going to be easy for the doc to blame the nurse rather than actually take responsibility.

Here.I.Stand, BSN, RN · Jan 9, 2018

Dosing by a subjective, non-verifiable number is stupid. By that practice, a nurse runs the real risk of not medicating appropriately.

I mean there are some who will underreport pain (my pharm prof would say "the bachelor Norwegian farmer type") -- they are determined to remain stoic. So POD#1 after a double knee replacement, pt is gritting his teeth, grimacing, and PT will be here in an hour. Is plain Tylenol appropriate vs an opioid -- ONLY because the pt rated their pain a 2? I've had pts do this but agree to meds after some education, e.g. "you look miserable, and you have PT in an hour. PT can be painful. I'm concerned that without treating your pain, your PT will be less effective -- if you can even do what the PT recommends. If you can't do PT, your healing will be significantly slower."

Conversely, there is the type who if conscious will always rate their pain an 11... is it appropriate to give a mg of Dilaudid when the pt's resp rate is 6 -- ONLY because the pt rated their pain an 11?

If pt care doesn't require critical thinking, if it's appropriate to mindlessly "follow orders," why have licensed nurses?

If my nursing judgment says the order is inappropriate -- say in the 1st example -- and the MD refused to write a reasonable order, I would probably suggest the pt that the opioid can't be given unless they rate it >5. :whistling:

nurseequestrian · Jan 9, 2018

Someone mentioned that most of these pain scales come from EMR templates. And that's very true at where I work. I'm not saying that the pain scale is not important, just that it seems to get easy for providers to just pick one So they can move on in the order.

Also, when I give pain medication outside the parameters there is a reason. I work on an oncology floor and we are always doing pain management. When we find a schedule of pain medication that is finally controlling their pain and they are not having any respiratory or BP complications, then I'm going to stick with the schedule we found works for that patient. I'm not going to not give them a dose because their pain is finally controlled. The pain medication will wear off and I'm going to be the reason they are in excruciating pain again. And when this happens that we are on a pain management schedule but the parameters are still listed, the provider is aware that we are doing a schedule. Or for example pre medicating someone before PT. Their pain might be low right now but it will be high soon. Also, for those of you worried about the legal consequences, I feel this is something that could be argued in court. And if I'm carefully monitoring the patient for any side effects, I don't believe any patient would "sue" me for helping to control their pain. As nurses we do have critical thinking skills and I think we get so worried about the very slim possibility of legal consequences for everything little thing we do that we forget to use those critical thinking skills. Now I'm also not saying that we should practice outside our scope or we shouldn't be aware of legal ramifications.

OldDude · Jan 9, 2018

Dosing by a subjective, non-verifiable number is stupid. By that practice, a nurse runs the real risk of not medicating appropriately.
I mean there are some who will underreport pain (my pharm prof would say "the bachelor Norwegian farmer type") -- they are determined to remain stoic. So POD#1 after a double knee replacement, pt is gritting his teeth, grimacing, and PT will be here in an hour. Is plain Tylenol appropriate vs an opioid -- ONLY because the pt rated their pain a 2? I've had pts do this but agree to meds after some education, e.g. "you look miserable, and you have PT in an hour. PT can be painful. I'm concerned that without treating your pain, your PT will be less effective -- if you can even do what the PT recommends. If you can't do PT, your healing will be significantly slower."
Conversely, there is the type who if conscious will always rate their pain an 11... is it appropriate to give a mg of Dilaudid when the pt's resp rate is 6 -- ONLY because the pt rated their pain an 11?
If pt care doesn't require critical thinking, if it's appropriate to mindlessly "follow orders," why have licensed nurses?
If my nursing judgment says the order is inappropriate -- say in the 1st example -- and the MD refused to write a reasonable order, I would probably suggest the pt that the opioid can't be given unless they rate it >5.

Amen!! The "pain scale" is likely the dumbest thing ever introduced into the medical field.